DOI: 10.1111/j.1365-263X.2010.01078.
Oral mucosal lesions during orthodontic treatment
MARINKA BARICEVIC1, MARINKA MRAVAK-STIPETIC1, MARTINA MAJSTOROVIC2,
MARIJAN BARANOVIC3, DENIS BARICEVIC4 & BOZANA LONCAR1
1
Department of Oral Medicine, School of Dental Medicine, University of Zagreb, Zagreb, Croatia, 2Department of
Pedodontics, School of Dental Medicine, University of Zagreb, Zagreb, Croatia, 3Department of Oral Surgery, General
Hospital, Slavonski Brod, Croatia, and 4Department of Internal Medicine, Clinical Hospital Jordanovac, Zagreb, Croatia
International Journal of Paediatric Dentistry 2011; 21: 96–102
Background. Oral mucosal lesions can result from
irritation caused by orthodontic appliances or mal-
occlusion, but their frequency is not known.
Aim. To examine the frequency of oral mucosal
lesions in wearers of orthodontic appliances in
comparison to children with malocclusion.
Design. This study comprised 111 subjects: 60
wearers of orthodontic appliances and 51 controls
(aged between 6 and 18 years). Type and severity
of mucosal lesions, their topography, gingival
inflammation, and oral hygiene status were deter-
mined by using clinical indices.
Results. Mucosal lesions were more present in
wearers of orthodontic appliances than in children
Introduction
Local tissue damage is one of the intraoral risks
during orthodontic treatment1. Ulcerations,
pain, and discomfort are frequent side effects,
which result from irritation caused mainly by
fixed orthodontic appliances2,3. Although
painful and unpleasant, lesions heal quickly
because of the fast metabolism of oral mucosa
in young and healthy orthodontic patients4.
However, oral lesions may result from
interactions of dental cast alloys and oral
tissues as well. These interactions result
from bacterial adherence, toxic, subtoxic, and
allergy effects caused by metal ions and
allergy5. Direct interactions between ortho-
dontic appliances and periodontal tissues may
present a considerable challenge1.
Besides, during orthodontic treatment with
fixed appliances, challenging oral hygiene sit-
Correspondence to:
Dr M. Baricevic, Department of Oral Medicine, School of
Dental Medicine, University of Zagreb, Gunduliceva 5,
Zagreb 10000, Croatia. E-mail: mbaranov@inet.hr
96 International Journal of Paediatric Dentistry Ó 2010 BSPD, IAPD and Blackwell Publishing Ltd
with malocclusion. Gingival inflammation, ero-
sion, ulceration, and contusion were the most
common findings in orthodontic patients. The
severity of gingival inflammation was in correla-
tion with oral hygiene status; the poorer oral
hygiene, the more severe gingival inflammation
was. Better oral hygiene status was found in chil-
dren during orthodontic treatment than in chil-
dren with malocclusion.
Conclusions. Orthodontic treatment carries a
higher risk of mucosal lesions and implies greater
awareness of better oral hygiene as shown by
the results of this study. Oral hygiene instruc-
tions and early treatment of oral lesions are
important considerations in better patient’s moti-
vation, treatment planning, and successful out-
come.
uation because of trapped food and oral deb-
ris around brackets could contribute to the
development of gingival inflammation6.
Recent literature reports quite a small num-
ber of studies dealing with frequency and
type of oral mucosal lesions during orthodon-
tic treatment. Conversely, clinical experience
shows that lesions of oral mucosa in wearers
of orthodontic appliances are pretty common
findings in everyday practice, thus affecting
the motivation and duration of orthodontic
therapy. Therefore, the aim of this study was
to examine the frequency and type of muco-
sal lesions in the wearers of orthodontic
appliances and to compare these results with
a control group of patients who were diag-
nosed malocclusion, and were not actively
involved in orthodontic treatment.
Material and methods
Study groups
The study comprised 111 patients, of which
60 were wearers of orthodontic appliances
Ó 2010 The Authors

(33 boys and 27 girls) and 51 (27 boys and
24 girls) were controls with malocclusion.
The patients’ age ranged from 6 to 18 years
(mean age 13.25 in the experimental group
and 11.86 in the control).
All children from the experimental group
were already in the orthodontic treatment
and were referred by the orthodontist for the
purpose of this study. To examine the associa-
tion between the types of orthodontic appli-
ances and oral mucosal lesions, subjects were
divided into three groups: wearers of remov-
able bimaxillary orthodontic appliances (18
patients), wearers of removable monomaxil-
lary appliances (24 patients), and wearers of
fixed orthodontic appliances (18 patients).
Children from the control group were
referred by their paediatric dentist because of
detected malocclusions that had not been
orthodontically treated.
In all patients, medical history was obtained
and oral examination was performed during
which oral lesions were detected and recorded
including gingival and mucosal inflammation
as well as oral hygiene status. Medical history
included data related to systemic diseases and
verified allergy to known allergens and medi-
cations. Exclusion criteria referred to all the
patients with systemic or chronic diseases,
allergy, and those patients who were taking
medications for any of the above mentioned
reasons.
The study was approved by the Ethical
Committee, School of Dental Medicine, Uni-
versity of Zagreb. Prior to signing a written
consent, each participant was thoroughly
explained the purpose of the study. As all the
subjects were under 18 years of age, prior to
commencing the study, a written consent was
required by their parents7.
Clinical examination
Oral medicine specialists performed oral
examination in all patients and detected oral
mucosal lesions in a standard manner using
procedure based on internationally accepted
criteria8. Lesions were recorded according to
their clinical appearance including surface
morphology, size, colour consistency, and
location, and were grouped in five categories:
Ó 2010 The Authors
International Journal of Paediatric Dentistry Ó 2010 BSPD, IAPD and Blackwell Publishing Ltd
Oral mucosal lesions during orthodontic treatment 97
inflammation, contusion, desquamation, ero-
sion, and ulceration. Such classification of
lesions was applied to unify criteria for assess-
ing lesions in both groups of patients. Only
mucosal lesions present at the time of exami-
nation were recorded.
The size of lesion was graded from 1 to 3: 1
indicating lesion up to 1 cm in size, 2 indicat-
ing lesion from 1 to 3 cm in size, and 3 indi-
cating lesion larger than 3 cm in size.
The severity of oral mucosa inflammation
was determined and graded based on the fol-
lowing clinical criteria9:
d Degree 1 indicates barely visible localized
inflammatory reaction presented by a
lighter red colour and <1 cm in diameter.
d Degree 2 indicates medium intensity of
inflammatory reaction, with moderately
red colour of oral mucosa varying
from degree 1 to 3; no more than 2 cm in
diameter.
d Degree 3 indicates severe inflammatory
reaction presented by a darker red colour,
spreading extensively more than 2 cm in
diameter.
The oral hygiene status and gingival inflam-
mation were recorded according to verified
clinical indices10,11.
Gingival inflammation was assessed by Löe
and Silness’ gingival index10:
d 0 = normal gingival
d 1 = mild inflammation, slight change in
colour, slight oedema, no bleeding on pal-
pation
d 2 = moderate inflammation, redness,
oedema, glazing, bleeding on palpation
d 3 = severe inflammation, marked redness
and oedema, ulceration, tendency to spon-
taneous bleeding
The oral hygiene status was determined
according to Silness and Löe’s plaque index11:
d 0 = without plaque deposits
d 1 = plaque is revealed by periodontal
explorer after gingival margin probing
d 2 = plaque is visible and involves a cervical
third of the tooth
d 3 = huge plaque deposits involving two-
thirds of the tooth
Modification from the applied Silness and
Löe’s plaque index was made only in those
children who did not have first bicuspids and
98 M. Baricevic et al.

lateral incisors at the time of conducting the (a)

survey. Instead, simplified oral hygiene index,
implying the same criteria, was used.
The topography of lesion was recorded
according to WHO scheme (Fig. 1), as pro-
posed by Roed-Petersen and Roenstrup8.

Statistical analysis
All data were analysed by using v2-test. Due
to low frequency of observed variables, Fish-
er’s exact test was used in a certain number
of cases. P-values <0.05 were considered as
statistically significant. In some cases, the
results were interpreted only in terms of
quality and without any assessment of statis-
tical significance.

Results
The frequency and distribution of oral muco-
sal lesions between groups is presented in
Fig. 2. One or more mucosal lesions were
found in 38 wearers of orthodontic appliances
(63%) and in 24 patients with malocclusion
(47%).
The most frequent lesions in the experi-
mental group were erosions (7%), ulcerations
(7%), contusions (7%), and desquamations
(5%) as a result of trauma caused by ortho- (b)
dontic appliance. Ulceration, erosion, and des-
quamation were mainly related to wearing
fixed orthodontic appliances, whereas ero-
sions and inflammation detected underneath
the appliance were more related to the use of
removable orthodontic appliances. Brackets
from fixed orthodontic appliance mostly
caused erosions and desquamations, whereas
archwire caused ulcerations (Fig. 3). In one
patient, mucocele developed due to constant,
slight pressure and friction of archwire to the
oral mucosa of the left cheek. In patients with
removable orthodontic appliances, inflamma-
tion under the palatal plate was the most
common finding, whereas less-frequent ero-
sions were present due to friction against pal-
atal screw, or desquamation found due to
irritation caused by interdental clasps (Figs 4
and 5).
All lesions were accompanied by inflamma- Fig. 1. (a and b) Topography of oral mucosa by WHO
tion, whereas inflammation as a solitary modified after Roed-Petersen and Renstrup.

Ó 2010 The Authors

International Journal of Paediatric Dentistry Ó 2010 BSPD, IAPD and Blackwell Publishing Ltd
 Oral mucosal lesions during orthodontic treatment 99

Fig. 4. Erosion on the tongue mucosa due to friction

against palatal screw.

Fig. 2. Distribution of all mucosal lesions found in

experimental and control group.

Fig. 5. Desquamation of the buccal mucosa as a result of

permanent mucosal irritation caused by interdental clasps.

Fig. 3. Aphthous ulcers on the lower lip mucosa.

Table 1. Intensity of oral mucosal inflammation between
groups.

diagnosed occurrence was only present under Inflammation Experimental group Control group
removable orthodontic appliance. Inflamma- intensity (number of patients) (number of patients)
tion intensity in both groups of patients was
1 (Weak) 12 15
mostly weak or medium (Table 1.). 2 (Medium) 23 8
The localization of mucosal lesions corre- 3 (Severe) 3 1
sponded to the spot where the orthodontic Mean intensity 1.76 1.41
appliance caused trauma. According to WHO
topography, injuries caused by fixed ortho-
dontic appliances were on the buccal and ves- or caused by aphthous stomatitis or viral
tibular mucosa as well as on the lower lip infection.
(regio 14, 17, 18, 19, 20, 24, 26, 29, 30), Gingival inflammation was the most fre-
whereas, in the wearers of removable ortho- quent finding in both groups of patients. In
dontic appliances, lesions were found on the orthodontic patients, gingival inflammation
hard palate, tongue, and vestibular mucosa of was present in 36.3% and 40.7% of control
the lower jaw (regio 24, 26, 39, 40, 51, 52). patients. In the wearers of fixed orthodontic
In children with malocclusion, lesions of appliances, gingival inflammation was most
oral mucosa occurred less frequently; the frequently found in marginal gingiva of the
most common were buccal and vestibular upper and lower jaws. In patients with mal-
erosions (5.1%), mainly resulted from biting, occlusion, inflammation was equally frequent

Ó 2010 The Authors

International Journal of Paediatric Dentistry Ó 2010 BSPD, IAPD and Blackwell Publishing Ltd
100 M. Baricevic et al.
in vestibular marginal gingiva of the upper
and lower jaws, as well as on the palatal sides
of marginal gingiva. A higher intensity of gin-
gival inflammation was present in the sub-
jects with fixed orthodontic appliances
compared with wearers of removable ortho-
dontic appliances.
Although no statistically significant differ-
ences were observed regarding oral hygiene
status among the wearers of orthodontic
appliance, poorer oral hygiene was found in
the wearers of fixed orthodontic appliances.
Subjects from the experimental group had a
better oral hygiene in comparison to control
group, yet with no statistically significant
differences (P > 0.05). The frequency and
intensity of gingival inflammation was in
correlation to the oral hygiene degree: the
poorer the oral hygiene, the more frequent
and intensive gingival inflammation was
(P < 0.05).
Gingival inflammation was evaluated
depending on a patient’s gender and age, as
well as the type of dentition. The inflamma-
tion was more frequent and of higher inten-
sity in boys (P > 0.05), in younger patients
(P > 0.05), and in subjects with mixed denti-
tion (P > 0.05), yet without any significant
differences either.
Discussion
In this study, mucosal lesions were more fre-
quently present in the wearers of orthodontic
appliances than in controls.
In the wearers of orthodontic appliances,
most mucosal lesions were related to trauma
caused by such appliances. Erosion and ulcera-
tion were the most frequent mucosal lesions
in wearers of fixed orthodontic appliance. Data
from Kvam et al.2 showed that among wearers
of fixed orthodontic appliances, 75.8% of
patients had small wounds, whereas 2.5% had
bad ulcerations, although clinical appearance
of small wounds was not described.
The localization of oral mucosal lesions
caused by fixed orthodontic appliances,
according to WHO scheme, was on buccal
and vestibular mucosa, where the archwire
and brackets caused erosions and desquama-
tions, and on the lower lip where brackets
International Journal of Paediatric Dentistry Ó 2010 BSPD, IAPD and Blackwell Publishing Ltd
and wire caused ulcerations. According to
Travess et al.1, ulceration or hyperplasia, in
the fixed orthodontic patients, resulted from
irritation caused by the arch wire and bonds,
or wire resting against the lips. In the wearers
of removable orthodontic appliances, mucosal
inflammation was the most frequent finding.
Inflammation of the palatal mucosa under
palatal plate was related to yeast infection,
whereas erosions mostly occurred as a result
of irritation caused by interdental clasps or
unsuitable habit caused by tongue pushing
the palatal screw and consequently resulting
in tongue injury.
Damaged epithelium of oral lesions in which
nerve endings are exposed provokes painful
sensation. Data from the literature mostly
focuses on pain as a consequence of applica-
tion of forces to induce tooth movement3,12–14
rather than pain resulting from oral mucosal
lesions15. According to Bergius et al.16, moti-
vation is the willingness to endure pain during
orthodontic treatment. Therefore, preventing
oral lesions means preventing pain and
increasing patient’s motivation.
Gingival inflammation was more frequently
observed in 77% of subjects from both
groups. The severity and frequency of gingival
inflammation was higher in patients with
poorer oral hygiene status. In the experimen-
tal group, the intensity of gingival inflamma-
tion was higher in wearers of fixed
orthodontic appliances compared with wear-
ers of removable orthodontic appliances. This
complies with other studies, which proved
that almost all patients’ wearers of fixed
orthodontic appliances experienced gingival
inflammation1,2,17. The localization of gingival
inflammation in these patients was present in
marginal gingiva of the upper and lower jaws.
According to Rafe et al.6, this site is where
plaque is usually accumulated in wearer of
fixed orthodontic appliances. Gingival inflam-
mation was more present in boys and youn-
ger patients as a result of poor oral hygiene.
Conversely, data from the literature suggested
that younger patients cooperate better18.
In the control group, gingival inflammation
was more present in subjects with poorer oral
hygiene and those having malocclusions such
as maxillary and mandibulary crowding,
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which interfered with physiological cleaning
due to saliva flow. This finding corresponds
with data from the literature that showed
lower frequency of gingival bleeding in wear-
ers of orthodontic appliances compared with
subjects who were not in orthodontic treat-
ment19,20.
Better oral hygiene was observed in wear-
ers of orthodontic appliances who previously
acquired oral hygiene instructions from their
orthodontist, before even such an orthodontic
treatment commenced. Ay et al.21 showed
that the oral hygiene motivation method per-
formed by patients under the supervision of
their clinician allowed more successful elimi-
nation of plaque as well as inflammatory
symptoms in patients with fixed orthodontic
appliances. In the wearers of orthodontic
appliances, the use of adjuncts such as electric
toothbrushes, interproximal brushes, chlorh-
exidine mouthwashes, fluoride mouthwashes,
and regular professional cleaning should be
introduced in an everyday hygiene regi-
men1,22. However, in performing oral hygiene
measures, the patient’s motivation is the key
to assessing satisfactory oral hygiene status.
Patients who were unable to maintain a
healthy oral environment in the absence of
orthodontic appliance had even worse oral
hygiene when fixed orthodontic appliances
were placed on the teeth1.
Among the studies we assessed, very few
were dealing with the frequency and type of
oral mucosal lesions in wearers of orthodon-
tic appliances. Therefore, this research was
undertaken to determine the frequency and
type of these lesions in both wearers of
orthodontic appliances and in children with
malocclusion. More mucosal lesions were
present in patients with orthodontic appli-
ances as a result of trauma. Clinical appear-
ance of mucosal lesions and their localization
were associated with the type of orthodontic
appliance. Being able to prevent and treat
these lesions would consequently reduce
pain and increase patients’ motivation. Fol-
lowing good oral hygiene instructions
acquired prior to starting the treatment is
vitally important in order to subsequently
avoid gingival inflammation and hard tissue
damage.
Ó 2010 The Authors
International Journal of Paediatric Dentistry Ó 2010 BSPD, IAPD and Blackwell Publishing Ltd
Oral mucosal lesions during orthodontic treatment 101
What this paper adds
d This study explores the frequency and type of oral
mucosal lesions in both wearers of orthodontic appli-
ances and children with malocclusion
d More lesions are found in wearers of orthodontic
appliances as a result of trauma
d The intensity of gingival inflammation was related to
oral hygiene status. The poorer the oral hygiene, the
more intensive the inflammation was.
Why this research is important for paediatric
dentists
d Oral mucosal lesions are more frequently found in
orthodontic patients than in patients with malocclu-
sion. Therefore, to be able to identify the type of
lesion as well as its ethological background plays an
important role in early diagnosis and treatment of
these lesions in order to avoid pain and accelerate
healing, which leads to improving oral function and
the quality of life in younger patients during ortho-
dontic treatment.
d Maintaining satisfactory oral hygiene habits is crucial
for further prevention of gingival inflammation and
hard tissue damage in both children with malocclusion
and children during orthodontic treatment.
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